What parents need to know about pigeon-toed or in-toeing

A child’s first attempts at walking aren’t always perfectly smooth, and there are some important things to be aware of as you watch your child’s shaky first steps develop into a steady walk. Dr. Victoria Kuester, orthopaedic surgeon and mom of two, highlights what can be helpful to know about in-toeing, a common condition that can become apparent with a child’s first steps and in the active years that follow. 

What is in-toeing? 

Many children walk with their toes pointed inward when they’re first learning and some continue to do this in the toddler years and beyond. The medical term for this is “in-toeing.” For some children, in-toeing (or walking “pigeon-toed” as it is also sometimes called) can appear to make a child’s walking pattern, or gait, abnormal.

While it can be worrisome to see a child to develop an abnormal gait, both in-toeing and gait abnormalities typically resolve as a child’s body matures and their walking skills improve.

What causes in-toeing?

In-toeing is typically caused by a curvature of the foot or a slight rotation of bones in the leg. There are three main physical issues that contribute to these causes and it is possible for a child to experience all three.

• Ages 18 months and younger – In children younger than 18 months, the front part of the foot turning inward is the most common cause of in-toeing. This condition, known as metatarsus adductus, affects one to two of every 1,000 newborns and is most likely a result of a child’s positioning in the womb. In these cases, the child was most likely positioned in the womb with the foot contorted to an inward position. Once the child is no longer in the womb, and the position is taken away, the curvature of the foot can improve to a more straight position. Nearly 85 percent of cases of metatarsus adductus resolve on their own within the first 18 months of life. Children with this condition may initially have feet that can be described as “bean-shaped.” Once resolved, a “line” drawn upward from the middle of the heel should end between the second and third toes on the bottom of a child’s foot.
• Ages 18 months to 3 years – The most common cause of in-toeing in the 18 month to 3-year-old age group is tibial torsion. This is the medical term for the inward rotation of the bone in the lower leg (the tibia). Most cases of tibial torsion are part of normal development as the tibia tends to rotate inward when a baby is formed in the womb and naturally rotate outward as a child’s body grows during the first three years of life. Although in some children the tibia starts out more inwardly rotated than others, 95 percent of cases of in-toeing due to tibial torsion gradually resolve on their own with growth and the natural outward rotation of the tibia by around 5 years of age.
• Ages 3 to 8 – In children ages 3-8, the most common cause of in-toeing is the position of the thighbone (femur). At birth, the top portion of the femur is rotated inward at about a 40 degree angle, but as a child matures the femur bone rotates naturally and the angle decreases to around 15 degrees. Most cases of femoral anteversion (the medical term for the rotating t of the femur) resolve by age 10 as the amount of rotation decreases with maturity. Until then, this condition can affect a how a child sits and walks. Children may tend to sit with their legs in a “W” position (knees together and feet spread to either side). They also may have a clumsy-looking running pattern in which the legs swing outward. Femoral anteversion improves in 99 percent of children.

When should a parent consult their child’s doctor or an orthopaedic specialist?

In rare cases, in-toeing and gait abnormalities can relate to other medical issues like cerebral palsy or spina bifida. If you are concerned about the way your child walks, talk with your child’s pediatrician to determine if testing, treatment or referral to an orthopaedic specialist is needed.

Also, be sure to talk to your child’s doctor if your child continues to experience in-toeing or gait abnormalities past the age they should have outgrown the issues outlined above; if your child’s foot appears stiff and not flexible; or if your child’s gait is affecting their function.

What treatments are available for in-toeing?

For children with metatarsus adductus, casts and special shoes can help with foot positioning if the curvature of a child’s foot does not improve on its own by about a year. Surgery is also an option if there is no improvement with these methods.

If a child reaches the age where they should have outgrown tibial torsion or femoral anteversion, and related issues are limiting a child’s function, surgery can be performed to turn the bones outward. Leg braces have been used to help treat tibial torsion and femoral anteversion, but they are no longer used for this type of treatment. Keep in mind that many people still in-toe at maturity and unless it is limiting an individual’s movement and abilities it does not need to be taken care of, but certainly can be if desired.

Dr. Victoria Kuester, Orthopaedic Surgeon

Dr. Kuester is part of the orthopaedic surgery team at CHoR. This team provides evaluation, diagnosis and treatment for a full range of orthopaedic issues ranging from broken bones and sports injuries to complex bone and muscular conditions present from birth.

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• Safer jumping: Important trampoline safety tips